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HomeMy Public PortalAbout5940, 5942, 5944 TEMPLE CITY BLVD_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION I hereby affirm that o have a certificate of consent self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.). Policy No. Company FOR APPLICANT TO FI LL IN BUILDING pCORESS .[� G�C A / Certified copy is hereby furnished. nc nR EssVAW LOCALITY Certified copy is filed with the county building inspection LOCALITY NEAREST department. CROSS ST. Date Applicant NEAREST �� DISTRICT NO. GROUP TYPE P ESSED BY CROSS ST. AAV CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL L,O COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAr STATE MAJOR SECOND LOCAL NO. (CIRCLET NO. OF BLDGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF 2 SIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this o permit is issued, I shall not employ any person in any manner OWNER so as to become subject to the Workers' Compensation Laws. MAIL S ® OCCUPANCY GROUP a U Date ADDRESS Applicant ,�y— LI.I NOTICE TO APPLICANT: If,after making this Certificate of CITY �l LE C/ ! NO. OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: Compensation provisions of the Labor Code,you must forth- with comply with such provisions or this permit shall be TRAILER USE ❑ GEOLOGY INSPECTION ❑ No Spec. Knowl. deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION X Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. C �L•� t �i� L� PARKING SPACES REO'D D PROVIDED License Number Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a PROM: TOS licensed architect or a registered professional engineer SIZE OFNO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus' EXISTING BLDG. STORIES SIGNATURE iness and Professions Code). 1:'(NAL PRESENT USE OF BUILDING APPROVAL Lic.or Reg.No. Date 1J,41R 54NO FEE HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Busi `�� f 4/93ness and Professions Code): NO. PARKING ❑ I, as owner of the property, will do the work and the SPACES PROVIDED 8491 1 PIN '2:20structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILOING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.Q. Lender's Name PROPOSED MAX. OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL FEE 2 upon the above-mentioned property for inspect'•n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE y Signature of Permittee Date \1'UIt1;IRS'('OMP[:NS1TIOtiDL'('L.11t.\TIOX t 1 aar E_87�fi 4 dMISCELLANEOUS APPLICATION vie I he:elly affirm that 1 have a certificate of consent to self insure. or a certificate of\Porkers'Compensation Insurance.or COUNTY OF LOS .a.!��CFEL�$ BUILDING AND SAFETY DIVISION III a certified copy thereof iSec.3800.Lab.C.1. ` Policy No. _Conivan} FOR APPLICANT TO FILL-IN BU iLDING Ar DRESS Certified copy is hereby furnished. eu1LDING rr g ADDRESS I�Q LO t_A LITY I I Certified copy is filed with the county buildine Inspection I OCALITY NEAREST department. j temple City CF:,OSS ST. Date__Applicant NEAREST 7 STR IC GR p TYPE P CESSED BY CRO55 ST. CONST. CERflFICATL•'OF EXEMPTiON FROM WORKERS' I LEGAL t— I COMPENSATION INSURANl!- SCRIPT:ON LOT NO. !BLOCK IMAM NIGNw Av STATE MAJOR SECOND LOCAL � NO, (CIRCLE) NO. OF BLDGS. Mlis section need not he enmpleted if the work involved {I RACT NOW ON LOT USI= ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ISi001 or less.! t usE OF r 1 Pu OF LOT I EXISTING BLDG. I , I certify that in :Ile performance of -Ile work 'or which •his ll� uTg n permit is issued. I ;(anal :lot employ an} ne:so:l :n am manner OWNER 1. reg Jackson i so as to become ;uhiect :o the 1Par ens i :npcnsa[ien 1. rs. OCCUPANCY GROUP —� — AaIL � n IJADDRE55 4 Date�_L<' •applicant _ -_ NOTICE To APPLICANT: it•if-c- makinc :!:is i ;Iffierfr c gj r_,T —F .laIL►(o2 OCCUP4N-LOAC Exemption. you dimild beL•ome subiect :o -lie t\IR'ers Compewrion provisions of-he Labor-.'.)de. you mus[ torch ILPDL!CATICN °�F .X 44RC!t!•1r E 1 with comniv wirli ouch nrovis:oir; .or his ^craps ;hall he n — II-RAILER USE iEO LJ GY :NFPE TIC 1 No Soec. <ncC ji, II deemed:III,;e,i. — LICENSED CONTRACTORS DECLARATION OCCUPANCY IN-SPECTION$$ Pan;c Dev;r:es ❑ 1 hereby :Iitirnl :Ir:I[ I alp Ilcensed lander previ<lons of Chapter I SAFET PERMIIT LIST ITEMS BELONi C 1 9 iconin;encine with Section -0001 of Division 3 .ii:he Susi- ` -- NO. OF EXITS I Hess and P-ol'cssion.Code.and mylicence !. in .'fail force and - El effect. PARKING REO'D I I PROVIDED y � SPa CES �J 0 License Number_ Lic. Class LIMITED TIME USE LL � w Contractor ...-. _--.---._...- Il:ite -._-- - DATE DA TIi W l and exempt from the :icensine -edulrenientc :Is 1 am .I a I licensed architect .r a registered professional engineer I'=1zE DF I No, o� INSPECTOR'S -I1C �y-XISTING SLOG. STORIE7 SIGN ATU z acrim_ in any prcf:!;ional :ata it; �a:ria:r 1. 13u;- _ _ a iness and l':ofessicn%Code I. RESENT USE OF BUILDING F i t L APPROVAL — ------ ! --- ^ Lic.or Ree. No. ---------- Dae— —--- '� x ( I HOME OWNHI-BUILDER DECLARA110N NO. OF EXISTING BUILDINGS � I ON LOT AND USE I hereby af:irin that 1 alp exempt from the Contractor's l I License Law for the following reason (Section -031.5. Busi- ness and Professions Code): NO. PARKING I, as owner of the pproperty. will du theworkork And tile SPACES PROVIDEDe !! structure is not intended or offered for tale (Section f 1 704.1.Business and Professions Code). I 1 ItIPR OPOSED USE OF BUILDING ad �� CONSTRUCTION LENDING AGENC)I k, I hereby affirm that there is a construction lendinu :wcnc% flrIA4-6 OS �p �Q 1 for the performance of the work for which this permit is -. issued(Sec. 3097•Cie.C.1. 1! 3 S iOnS ilt� `'I `" Lender's Name.. ----_—._-• � '�' I=-•J I� �1 r to LSI & OPOSED MAX. OCC. Lender's:Address CD I I certify that l have read this application and state that the PERM( FEE 25.0 V above information is correct.1 aeree to comply with all County ISSUANCE FEE 1- � ordinances and State laws relating to building construction, j• Y and hereby authorize representatives of this County to enter TOTAL FEE 25.00 1 I upon the above-mentioned property for inspection purposes, l '- SEE REVERSE I-OR EXPLANATORI' LANGUAGE r...! Sienatllrc rf Permittee D:atc 10 r ! =c• •G I "`"R!:'.1(s'`'°"IPCNSA'rlUN DECLARATION ,�113nt444 MISCELLANEOUS APPLICATION , E 137s(11-84) lereby affirm that t have a certificate of consent to self COUNTY OF LOS ANGELES MK 1 insure, or a certificate of Workers'Compensationlnsurance,ler k , ._. 130ILDING ANI) SAFETY DIVISION a certified copy thereof(Sec. 3800,Lab.C.). } i'aatiLy No. ...... .._ t':anlp:lny.._ FOR APPLICANT TO FILL IN BAAU'LarNc D DRES ElCertified copy is hereby furnished. BUILDING Xk ADDRESS 5944 N. TEMPLE CITY BLVD. LOCALITY Certified Py is filed with the county building inspection Q LOCALITY N. OF LAS TUNAS, S. OF WOODROOF moss ST department. . D3IC Appllca III___—__ -- NEAREST 1 1 n DISTRICT NO. GROUP TYPE CESSED BY GROSS ST. WOODROOFD� / CONS . C ERTIFICATE OF EXEMPTION FROM WORKERS' A I LEGAL .1 CO"(PENSA-170N iNSURANCE DESCRIPTION LOT NO. BLOCK MAP7 HIGHWAYNO STATE MAJOR SECOND LOCAL NO. (CIRC LC) (This section need not be completed if lite Work involved TRACT NOWOON LOT S. USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars-(SI00) or less.) USK or S- icertify that in the performance of the work for which this SIZE OF LOT EXISTING BLDGe permil is issued, I shall not employ any person in any manneXX' OWNER of building CHARLES JACKSON =� u+ as to hrct+nue stthjrct to tilt Workers't'nsnpensgtiran taws. MAIL OCCUPANCY GROUP D ADDRESS 6342 N. TRELAWNEY AVE. C') Date.___ Applicant—.__._.— w L. N0110E I'() APPLICANT: If.after making this Certificate of 1 CITY TEMPLE CITY NO. (818) 285-1462 OCCUPANT LOAD cin I•:remption, you should become subject to the Workers APPL{CATtON FOR EXIT HARDWARE: Compensation provisions of the Labor Code, you must forth- uitlr comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION[] NO Spec. ICnowi, deemed revoked. ❑ LIOCCUPANCY INSPECTION❑ Panic Devices LICENSED('UN'i'RAC'1'URS DECLARATION I hereby affirm that i ant licensed under provisions of Chapter SAFETY PERMIT[] (LIST ITE 9 (commencing with Section 7000) of Division 3 of the Busi- MS BELOwI No.OF EXITS Hess and Professions Code,and my license is in flet(fore anX r'� �7 effect. Name of business PARKING RSq'b ! J p,ROVrDED SPACES tTM License Number. _ _ Lic.Class CAT. WEST SUPIPT.Y.110- LIMITED TIME USE Contractor .. ._ .._._.._ .... Date—_---- O ATE OA TC i and exempt from the licensing requirements as 1 am a FROM. TO: • licensed architect or a registered professional engineer. SIZE OFryo.OF 7 INSPECTORS ` 6 acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. APPROX. 900 SFX RIES SIGNATURE inessand Professions C:ode). FINAL APPROVAL �1n Lia or Reg.Na._ ._._._ _ Date PRESENT USE OF BUILDING NONE n An IlO"ll:OWNER-1111ILDER i)ECLARATION NO. OF EXISTING BUILDINGS V,b ON LOT AND USE 1 hereby ai7inn that tam exempt fmm the Contractor's it License Law for file following reast+n (,Section 7031.5. Busy- i ness and Professions Code): NO. PARKING 1, as owner of file property, will do the work and the SPACES PROVIDED i structure is not intended or offered for sale (Section i 7044,Business and Professions Code). }} C ONSTRUC:'1'ION LENDING AGENCY PROPOSED USE OF BUILDING 7 1 hereby affirms that there is a construction lending agency PIPE AND FITTINGS for t{te performance of lite work for which this permit is t issued(Sec.3097,Civ.C.). rI L.cndcr's Name__.._,......_.----_--••_—_-- .I `= � �. PROPOSED MAX*OCC. ,t Lender's Address _. .. _. ..-_ PERMIT FEE t certify that 1 have read this application an d state that the above inforntalion is correct.1 agree to comply with all County ISSUANCE FEE 1 - ordinances and Slate laws relating to building construction, I i Ti:and hereby authorize representatives of this County to enter i TOTAL FEE 25.00 k .; upon fhc about m nIittned prtaperty for inspection pi rposeS. I XX SEE:REVERSE FOR EXPLANATORY LANGUAGE •n Iluu•„1 frim' IPI 1a:1 t• i i +�I WORKERS'COMPENSATION DECLARATION �ISM444 CE 875(11-84) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent tself COUNTY OF LOS A-INGELtES BUILDING AND SAFETY DIVISION I I insure, or a certificate of Workers'Compensation Insurance, e,or >�1 a certified copy thereof(Sec.3800,Lab.Q. �LLJJ Policy No. Company FOR APPLICANT TO FILL IN BUILDING ADDRESS Certified copy is hereby furnished. BUILDING ADDRESS LOCALITY 0 CerCepa tmeied npy is filed with the county building inspection LOCALITY Temple City NEAREST ST. Date Applicant NEAREST OISTRI NO GR TYPE MESSED BY CROSS ST. CONST. ` CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL � GLL� COMPENSATION INSURANCE DESCRIPTION LOT NO. BLOCK MAP HIGHWAY ND. (CIRCLE) STATE MAJOR SECOND LOCAL NO. OF SLOGS. (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONESPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE OF iSIZE OF LOT EXISTING BLDG. I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner OWNER Johnson so as to become subject to the Workers' Compensation Laws. MAIL OCCUPANCY GROUP1Z:1 ESS � , J Date ADDRI Applicant NOTICE TO APPLICANT: If,after making this Certificate of CITY 3 Z T L. b/7SqCCUPANT LOAD Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code,you must forth- (17b APPLICATION FOR EXIT HARDWARE: with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION ❑ ` deemed revoked. F] ❑ No Spec. Knowl. I LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION XX Panic Devices I I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT 9 (commencing with Section 7000) of Division 3 of the Busr ❑ (LIST ITEMS BELOW) NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REp'D PROVIDED License Number SP'A CES Lic. Class LIMITED TIME USE Contractor Date DATE DATE I am exempt from the licensing requirements as I am a FROM: TO: licensed architect or a registered professional engineer SIZE OF NO.OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. so STORIES SIGN RE iness and Professions Code). FINAL APPROVAL Lic.or Reg.No. Date PRESENT USE OF BUILDING Z. I HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS W1 ON LOT AND USE � I �. �_ I hereby affirm that I am exempt from the Contractor's +}� License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING 0 I, as owner of the property, will do PROVIDED do the work and the O. structure is not intended or offered for sale (Section - �.I 7044,Business and Professions Code). p CONSTRUCTION LENDING AGENCY X PROPOSED USE OF BUILDING I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is 10 issued(Sec.3097,Civ.C.). Lender's Name Yr Lender's Address PERMIT FEE 25.00 PROPOSED MAX. OCC. I certify that I have read this application and state that the above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize representatives of this County to enter TOTAL.FEE 25.00 upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE s ' Signature of Permittee Date .J